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Procedure Performed: Lipa City Colleges ODC Form 1

The document contains forms from Lipa City Colleges for nursing students to document procedures performed in clinical settings, including surgical scrubs, deliveries, and other procedures. The forms require signatures from the student, supervising instructor, clinical coordinator, chief nurse, and dean to verify the procedure was completed and supervised appropriately according to the school's standards.

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Rita Honrade Hernandez
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108 views5 pages

Procedure Performed: Lipa City Colleges ODC Form 1

The document contains forms from Lipa City Colleges for nursing students to document procedures performed in clinical settings, including surgical scrubs, deliveries, and other procedures. The forms require signatures from the student, supervising instructor, clinical coordinator, chief nurse, and dean to verify the procedure was completed and supervised appropriately according to the school's standards.

Uploaded by

Rita Honrade Hernandez
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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LIPA CITY COLLEGES

# 10 G.A. Solis St., Lipa City, Batangas (043) 756-1943, (043) 756-3768, (043) 756-5974, [email protected], www.lipacitycolleges.net (CHED RECOGNIZED No. 11, 1992/ PACUCOA ACCREDITED: LEVEL I STATUS, January 9, 2009-2011) SURGICAL SCRUB (MAJOR) in ________________________________________________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student _____________________________________________________ Date Performed and Time Started Patients Name Case Number

ODC Form 1
OR SCRUB FORM

Signature of Student ___________________________________

PROCEDURE PERFORMED

O.R. Nurse On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUBY G. DELA CRUZ Clinical Coordinator, PRC I.D. No.: 0360712 Valid Until: NOVEMBER 2010 PNA No.: 002454 Valid Until: DECEMBER 2010 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2012 PNA No.: 03296 Valid Until: DECEMBER 2010 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2012 PNA No.: 03296 Valid Until: DECEMBER 2010 Date document is signed: ______________________ Time: _________ Please specify Highest Nursing Degree Earned: M.A.N.

Approved by: DULCE I. LIBUIT Dean, PRC I.D. No.: 0196088 Valid Until: OCTOBER 2012 PNA No.: 002453 Valid Until: DECEMBER 2010 ADPCN No.: 172 Valid Until: DECEMBER 2010 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: Ed.D

Concurred by: GLADY EDITH T. TECSON Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2012 PNA No.: 03296 Valid Until: DECEMBER 2010 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2012 PNA No.: 03296 Valid Until: DECEMBER 2010 Date document is signed: ______________________ Time: _________ Please specify Highest Nursing Degree Earned: M.A.N.

LIPA CITY COLLEGES


# 10 G.A. Solis St., Lipa City, Batangas (043) 756-1943, (043) 756-3768, (043) 756-5974, [email protected], www.lipacitycolleges.net (CHED RECOGNIZED No. 11, 1992/ PACUCOA ACCREDITED: LEVEL I STATUS, January 9, 2009-2011) SURGICAL SCRUB (MINOR) in ________________________________________________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student _____________________________________________________ Date Performed and Time Started Patients Name Case Number

ODC Form 2
OR SCRUB FORM

Signature of Student ___________________________________

PROCEDURE PERFORMED

O.R. Nurse On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUBY G. DELA CRUZ Clinical Coordinator, PRC I.D. No.: 0360712 Valid Until: NOVEMBER 2010 PNA No.: 03208 Valid Until: DECEMBER 2009 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ______________________Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ______________________Time: __________ Please specify Highest Nursing Degree Earned: M.A.N.

Approved by: DULCE I. LIBUIT Dean, PRC I.D. No.: 0196088 Valid Until: OCTOBER 2010 PNA No.: 03208 Valid Until: DECEMBER 2009 ADPCN No.: 172 Valid Until: DECEMBER 2009 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: Ed.D

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ______________________Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: _____________________Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

LIPA CITY COLLEGES


# 10 G.A. Solis St., Lipa City, Batangas (043) 756-1943, (043) 756-3768, (043) 756-5974, [email protected], www.lipacitycolleges.net (CHED RECOGNIZED No. 11, 1992/ PACUCOA ACCREDITED: LEVEL I STATUS, January 9, 2009-2011) ACTUAL DELIVERY in ________________________________________________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student _____________________________________________________ Date Performed and Time Started Patients Name Case Number

ODC Form 3
DR ACTUAL DELIVERY

Signature of Student ______________________________

PROCEDURE PERFORMED

D.R. Nurse/Midwife On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUBY G. DELA CRUZ , R.N., M.A.N. Clinical Coordinator, PRC I.D. No.: 0360712 Valid Until: NOVEMBER 2010 PNA No.: 03208 Valid Until: DECEMBER 2009 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Approved by: DULCE I. LIBUIT, R.N., M.A.N., Ed.D Dean, PRC I.D. No.: 0196088 Valid Until: OCTOBER 2010 PNA No.: 03208 Valid Until: DECEMBER 2009 ADPCN No.: 172 Valid Until: DECEMBER 2009 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: Ed.D

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

LIPA CITY COLLEGES


# 10 G.A. Solis St., Lipa City, Batangas (043) 756-1943, (043) 756-3768, (043) 756-5974, [email protected], www.lipacitycolleges.net (CHED RECOGNIZED No. 11, 1992/ PACUCOA ACCREDITED: LEVEL I STATUS, January 9, 2009-2011) ASSISTED DELIVERY in ________________________________________________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student _____________________________________________________ Date Performed and Time Started Patients Name Case Number

ODC Form 4
DR ASSIST

Signature of Student ___________________________________

PROCEDURE PERFORMED

D.R. Nurse/Midwife On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUBY G. DELA CRUZ , R.N., M.A.N. Clinical Coordinator, PRC I.D. No.: 0360712 Valid Until: NOVEMBER 2010 PNA No.: 02454 Valid Until: OCTOBER 2010 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ___________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Approved by: DULCE I. LIBUIT, R.N., M.A.N., Ed.D Dean, PRC I.D. No.: 0196088 Valid Until: OCTOBER 2010 PNA No.: 02453 Valid Until: OCTOBER 2010 ADPCN No.: 172 Valid Until: DECEMBER 2012 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: Ed.D

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N. Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ___________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

LIPA CITY COLLEGES


# 10 G.A. Solis St., Lipa City, Batangas (043) 756-1943, (043) 756-3768, (043) 756-5974, [email protected], www.lipacitycolleges.net (CHED RECOGNIZED No. 11, 1992/ PACUCOA ACCREDITED: LEVEL I STATUS, January 9, 2009-2011) IMMEDIATE NEWBORN CORD CARE in ________________________________________________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student ______________________________________________________ Date Performed and Time Started Patients Name Case Number

ODC Form 5
IMMEDIATE NEWBORN CORD CARE

Signature of Student ___________________________________

Immediate Newborn Cord Care PERFORMED


Indicate where performed (e.g. DR, NICU, Nursery, or Home)

D.R. Nurse/Midwife On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUBY G. DELA CRUZ , R.N., M.A.N. Clinical Coordinator, PRC I.D. No.: 0360712 Valid Until: NOVEMBER 2010 PNA No.: 02454 Valid Until: OCTOBER 2010 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ______________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Approved by: DULCE I. LIBUIT, R.N., M.A.N., Ed.D Dean, PRC I.D. No.: 0196088 Valid Until: OCTOBER 2012 PNA No.: 02453 Valid Until: OCTOBER 2010 ADPCN No.: 172 Valid Until: DECEMBER 2010 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: Ed.D

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: _____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

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